Nail Disorders

Asst. Prof, Al-Muriesh

Maher
 Nail disorders
Learning objectives
● Understand the anatomy of the nail organ
● Recognize nail changes
● Congenial & Hereditary nail diseases
● The nail in dermatological diseases
● The nail in systemic diseases
Dermatology , Edited by Jean L. Bolognia , Julie V. Schaffer , Lorenzo Cerroni Fourth edition
Dermatology , Edited by Jean L. Bolognia , Julie V. Schaffer , Lorenzo Cerroni Fourth edition
Dermatology , Edited by Jean L. Bolognia , Julie V. Schaffer , Lorenzo Cerroni Fourth edition
 Nail disorders

Nail Signs Due to Abnormal Nail Matrix Function

Beau’s lines

Dermatology , Edited by Jean L. Bolognia , Julie V. Schaffer , Lorenzo Cerroni Fourth edition
Nail disorders Beau’s lines

Beau’s lines

iao, C., Aronowitz, P.B. Beau’s Toes. J GEN INTERN MED 35, 2467 (2020).
Beau’s lines
 Beau’s lines

A Text Atlas of Nail Disorders Techniques in Investigation, Edited Robert Baran et al. third edition
 1.Beau’s lines

• Transverse, band-like depressions extending from

one lateral edge of the nail to the other,
• and affecting all nails at corresponding levels

• Beau’s lines are caused by temporary disruption in

the growth of proximal nail matrix.
• Most often due to trauma or dermatological
disorder (manicures, onychotillomania) or
dermatologic disease of the proximal nail fold (e.g.
eczema, chronic paronychia).
• Involvement of multiple digits suggests a systemic
cause
• The distal limit of the furrow, if abrupt, indicates a
sudden attack of disease; if sloping, a more
protracted onset.

If the disease can completely inhibit the activity of the matrix for
1–2 weeks or longer, the transverse depression will result in total
division of the nail plate, a defect known as ‘onychomadesis’
 Differential diagnosis

• Mees’ lines (true leukonychia)

• Muehrcke’s lines (apparent leukonychia)
• melanonychia
Palpable depression and non-blanchability
differentiate Beau’s lines from Mees’ lines, other
differential are Muehrcke’s lines and melanonychia
 Nail Signs Due to Abnormal Nail Matrix Function

Transverse lines of the fingernails. (A) Beau's lines

(arrows) of the thumbnail. (B) Mees' lines (arrowheads) of
the thumbnail.Song, Ik-Chan, and Hyo Jin Lee. "Transverse Lines of the Nails." The American Journal
of Medicine 130.6 (2017): e259-e260
(A) Mees lines (arrows) in the fingernails of a 27-year-old woman. (B) Beau
lines (arrowheads) in the fingernails of a 41-year-old woman.
Huang, Tzu-Chuan, and Tsu-Yi Chao. "Mees lines and Beau lines after
chemotherapy." CMAJ 182.3 (2010): E149-E149.
Muehrcke lines
Muehrcke lines are paired lines that fade
when you press on them. Mees' lines are
single lines that won't fade with pressure
melanonychia
Treatment

There isn't a treatment for Beau's lines.

But treating the underlying cause can
keep them from coming back once they
grow out.
 Onychomadesis
(nail shedding)

Dermatology , Edited by Jean L. Bolognia , Julie V. Schaffer , Lorenzo Cerroni Fourth edition
 Onychomadesis
Ciastko, Allen R. "Onychomadesis and Kawasaki disease." Cmaj 166.8 (2002): 1069-1069.
Onychomadesis
(nail shedding)

Bassi A, Greco A, de Martino M. Arch Dis Child Fetal Neonatal

Ed
2.Onychomadesis (nail shedding)

Proximal detachment of the nail that is most often

due to trauma
Similar involvement of multiple digits suggests a
systemic cause
 Pitting

A Text Atlas of Nail Disorders Techniques in Investigation, Edited Robert Baran et al. third edition
 Pitting

Moreno-Romero, Juan A., and Ramon Grimalt. "Nail Pitting in

Psoriasis." N Engl J Med 379.22 (2018): e39.
 3. Pitting

Pitting describes the presence of punctate

depressions of the nail plate surface that can have an
irregular outline
Pits are due to foci of abnormal keratinization of the
proximal nail matrix which result in clusters of
parakeratotic cells within the dorsal nail plate.
In the proximal plate, these clusters appear as
nontransparent collections of scale. Over time,
shedding of the parakeratotic cells leads to the
appearance of pits. These pits migrate distally with
nail growth.
Large, deep and irregular pits are common in psoriasis
and eczema, Small, superficial and regular pits are
typical of alopecia areata
An isolated pit is not diagnostic and may be dye to
minor trauma
 Pitting in
Pitting in
alopecia areata
psoriasis
 Onychorrhexis

https://tangsclinical.com/?p=6334
Onychorrhexis
 Onychorrhexis

https://healthjade.net/onychorrhexis/
Onychorrhexis due to lichen planus

https://healthjade.net/onychorrhexis/
Median canaliform nail dystrophy
 4. Onychorrhexis

Onychorrhexis is characterized by longitudinal ridging

and fissuring of the nail plate. The depth of the ridges
can vary as can the extent of involvement, Diseases
commonly responsible for onychorrhexis include
lichen planus, impaired vascular supply, trauma, and
tumors that compress the nail matrix.
Trachyonychia
 Trachyonychia with AA

Chelidze, Khatiya, and Shari R. Lipner. "Nail changes in alopecia areata: an update and review." International
journal of dermatology 57.7 (2018): 776-783.
 Trachyonychia with LP

Dermatology , Edited by Jean L. Bolognia , Julie V. Schaffer , Lorenzo Cerroni Fourth edition
 5. Trachyonychia (twenty-nail dystrophy,
sandpapered nails

The term ‘twenty-nail dystrophy’ or trachyonychia

describes a spectrum of nail plate surface
abnormalities that result in nail roughness
Patients with trachyonychia can be divided into two
main groups:
1 Trachyonychia and a past history or clinical evidence
of alopecia areata.
2 Isolated nail involvement (idiopathic trachyonychia).
 Congenital Leukonychia .

Punctate leukonychia
 6. leukonychia

White nails are the most common form of colour

change. These can be divided into the
following main types:
1 True leukonychia, in which the nail plate is involved.
2 Apparent leukonychia, with involvement of the
subungual tissue. (Nail Signs Due to Nail Bed Disorders)
3 Pseudoleukonychia.
 Koilonychia (spoon nails)

https://www.healthline.com/health/spoon-nails-koilonychia#pictures
https://blog.feetlife.co.uk/nailcare/what-are-
spoon-shaped-nails/
 7.Koilonychia (spoon nails)

The nail plate is thinned and flattened with upward

eversion of its
lateral and distal edges, leading to a concave spoon-
like shape
Nail Signs Due to Nail Bed Disorders
Half-and-half nails
Muehrcke lines
Reproduced with permission from: Stedman's Medical
Dictionary. Copyright © 2008 Lippincott Williams &
Wilkins.

Splinter hemorrhages
Splinter hemorrhages of the great
toe
 1.Splinter hemorrhages

Splinter hemorrhages appear as one or more red–

brown to purple–black, thin longitudinal lines in the
distal portion of the nail
 Onycholysis

Psoriatic nail
Nail dystrophy of lichen planus
 2.Onycholysis

The distal nail plate is detached from the nail bed and
usually appears white because of the presence of air
in the subungual space. If an exogenous
pigment is present, the nail may appear yellow (fungi
and exudate) to green–black (pyocyanin).
Diseases commonly responsible for onychorrhexis
include : lichen planus, impaired vascular supply,
trauma, and tumors that compress
the nail matrix. The differential diagnosis includes the
common phenomenon of age-related ridging of the
nail plate.
Nail Signs Due to
Deposition of Pigment
Deposition of Pigment
Longitudinal brown to black band
Common in darkly pigmented individuals
Single band may be a sign of melanocyte activation or
proliferation (nevus, melanoma)
Multiple bands point to physiologic, trauma/
onychotillomania, drugs or systemic disease
CONGENITAL AND HEREDITARY NAIL
DISEASES
Congenital malalignment of the big toenail

Wagner, G. and Sachse, M.M. (2012), Congenital malalignment of the big toe
nail. JDDG: Journal der Deutschen Dermatologischen Gesellschaft, 10: 326-
330
 Congenital malalignment of the big toenail
Usually bilateral
nail plate of the big toenail deviates laterally from
longitudinal axis of the distal phalanx
the nail has a triangular shape, is thick opaque and yellow-
brown wih multiple Beau’s lines
lateral or distal nail embedding is a common complication
noticed by the parents only when the nails are severely
dystrophic or ingrown
Pachyonychia Congenita
 Pachyonychia Congenita

The characteristic finding is a thickened nail

with an increased transverse curvature due to severe nail
bed hyperkeratosis. Affected nails are extremely hard
and difficult to trim.
THE NAIL IN DERMATOLOGIC
DISEASES
 Psoriasis

irregular pitting, nail bed“oil drops”, and

onycholysis with an erythematous border
(diagnostic) other abnormalities include
splinter hemorrhages, subungual hyperkeratosis,
nail plate thickening and crumbling, and paronychia
Treatment
 Lichen planus
, nail thinning, longitudinal ridging and fissuring, and dorsal
pterygium (due to scarring). The combination of fissuring
plus atrophy can lead to a deformity likened to “angel’s
wings”.
 Treatment
Treatment with systemic corticosteroids may be required
to avoid pterygium formation. Intralesional injections of
corticosteroid (2.5–5 mg/ml triamcinolone acetonide in
saline) may be utilized when the disease involves a few
nails.
 Alopecia areata
geometric pitting, trachyonychia, punctate leukonychia,
erythema of the lunula, and onychomadesis

Treatment : cluding oral, topical and intralesional

corticosteroids, immunosuppressants, cyclosporin,
PUVA, and Jak inhibitor
 Eczema
pitting and Beau’s lines; onychomadesis, subungual
hyperkeratosis,onycholysis, and fissuring of the
hyponychium

Controlling the skin disease results in gradual

improvement of the nails.
THE NAIL IN SYSTEMIC
DISEASES
Clubbing
 1.Clubbing (Watch-Glass Nails, Hippocratic
Fingers, Drumstick Fingers)
Clubbing is caused by enlargement of the soft tissue
of the distal digit, leading to a bulbous appearance.
The nail plate is enlarged and
excessively curved, with widening of the angle
between the proximal
nail fold and the nail plate to greater than 180°
(Lovibond’s sign)
 2.Yellow Nail Syndrome

Yellow nail syndrome is an uncommon disorder of

unknown etiology
Linear nail growth is arrested or greatly reduced. The
nails are thickened and transversely and longitudinally
overcurved with disappearance of the cuticle. The nail
color varies from pale yellow to dark yellow–green
Characteristically, the nail abnormalities are
associated with lymphedema
and respiratory tract involvement, including chronic
bronchitis, bronchiectasis, sinusitis, and pleural
effusions.
 Treatment

Treatment is not effective in all cases and must be

prescribed for several
months19: • vitamin E 1200 IU/day • pulse
itraconazole (200 mg twice daily for 1 week a month)
or
fluconazole (150 mg daily for 1 week a month)
Muehrcke’s nails: chemotherapy

Half-and-half nails : chronic renal disease

Terry’s nails: liver cirrhosis

Terry’s nails
Courtesy of Bianca Maria Piraccini, ESPD annual meeting 2017 nail disorder in
Childerm
 Acute paronychia

The affected digit becomes swollen, red, and

painful purulent drainage.
Acute paronychia is most commonly due to
bacteria, in particular Staphylococcus aureus or
Streptococcus pyogenes
follows minor trauma to the nail
Recurrent episodes of acute paronychia should
raise the suspicion of an HSV
 Treatment

Drainage of the abscess, followed by systemic

antibiotics (based upon culture results) or
systemic antivirals when due to HSV.
 Nail biting

Rare before the of 3 years, peaks in childhood

and adolescence
prevalence of about 30% at around 6 year of age
occurs as a result of boredom or working on
difficult problems rather than anxiety
Halteh et al. J Dermatolog Treat. 2017;28: 166-172.
Shortening of fingernail, with transverse axes longer than
longitudinal ones, the hyponychium and nail bed skin become
visible
 Nail biting
Complications
• change in the oral bacteria (< Enterobacteriaceae)
• dental problems: apical root resorption, alveolar destruction, malocclusions, temporo-
mandibular disorders and gum injuries.
• negative social and psychological
consequences for the patients and
their parents

Periungual warts are a

common complication!
 Nail biting
Treatment
• Non-pharmacological therapies

Halteh et al. J Dermatolog Treat. 2017;28: 166-172.

 Nail biting
Treatment

• bitter tasting lacquers (containing denatonium benzoate and

sucrose octaacetate)

• non-removable reminder technique

Koritzky & Yechiam. Behav Modif. 2011; 35: 511-30.

 Nail biting
Treatment
• N-acetyl cysteine (NAC) 800-1200 mg/day

Ghanizadeh et al. Antiinflamm Antiallergy Agents Med Chem. 2013; 12: 223-8.
Deanety al. J Psych Neurosc 2011; 36: 78–86.
Thanks
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Email : almurieshmaher@gmail.com